Monthly Archives: August 2012

One of the symptoms of an OREX intern, I feel, is that you have a mild sense of insomnia the night before your observation. I guess it is because of the excitement and anticipation. I was actually up before my alarm went off at 6:30am. I got dressed and was out the door. I arrived at the 0A2 just in time. By 7:30AM the doctors and medical students begin to trickle in as they do. I was excited to see that Dr. Harken was lecturing today and I should be because the topic was about recovery and survival rates of patients with varying oxygen content in their blood. Dr. Harken started the lecture with the question, “what would heal faster, an incision on the head or the toe of a diabetic?” If you didn’t know anything about diabetics, you should know that a common and morbid effect of diabetics is the need to amputate limbs due to poor vascular circulation. Dr. Harken explained that the oxygen content in the blood makes a huge difference in the survival of the body or the organ it supplies. Dr. Harken then went in to describe a retrospective research that collected 75 patients that have been involved in an accident that caused the patient to drop to a blood pressure less than 90. The study then split the group into two, 35 patients were treated with standard levels of oxygen in their blood and the other 40 patients were treated with some chemical or hormone that increased their oxygen content to a hyper oxygenated state. The results of the studied showed that if you had your oxygen content increased either naturally or artificially, you had a 0% mortality rate in the operating room. Regardless if you were in either groups, if your oxygen content could not increase to the hyper oxygenated state, then you had a 30% chance of mortality. The researchers were not able to determine the underlying cause that permitted a treated or untreated patient with the chemical to reach hyper oxygenated states. The beauty and beast of science is that with every answered question paves the way to countless more unanswered questions. I left the lecture room a bit more confused than when I came in. But again, Dr. Harken’s objective of these lectures is to get you thinking and surely enough, he got me thinking.

The highlight surgery of my day goes to an incision and drainage of a right knee of a middle aged Filipino male. The patient’s knee had a large opening about a foot long that extend from his lower thigh, across his knee, and down to the middle of his lower leg. The doctors had the gash filled with a black absorbent sponge that was sutured in place. I have never seen this done before and was taken back at the site of the sponges as it appeared, from afar, as implants or ingrown black fungus patches on the surface of his skin. When I realized it was sponges, I breath a breathe of relief for the patient because for a moment I thought I was in some horror movie! What appeared as a wound from a freak accident actually had no collision based origin at all. Actually, the patient’s wound was caused by an initial bone infection I believed that ballooned up forcing the surgeons to cut open and operate on the leg. What complicated this injury even further was that the patient had diabetes that decreased the circulation in his legs which probably caused the patient to develop his end stage renal disease. End state renal disease is a condition where you kidneys are no longer function and you would need to have a kidney transplant or get kidney dialysis for the rest of your life. This would make recover and healing a difficult challenge for the patient and the doctors. The point of the surgery was to remove the sponges, drain the wound of blood and tissue debris, and then suture sponges back in. Thus they called this an incision and drainage operation. A big objective of the surgery was to acquire blood and tissue sample from various regions of the gash to test for infection. Even if all goes well, because of the patient condition, there is a great of amputation later down the road.

The surgeon for this operation was Dr. Billings who is the oldest and wises surgeon you will meet at highland hospital. Despite his age, Dr. Billings is very affable at heart, loves to travel, and will share his stories to those that have the pleasure of his company. The surgery initiated with the removal of the sutures that held the black sponge in place. Once the sutures were removed and the sponges were taken out, blood began to spill out. The blood was slowly mopped up after several towels, yet blood continued to drip out. There was so much blood lost that the patient needed a unit of blood. Once most of the blood has been wiped up, you can see the bones of the patient’s femur and the knee joint. The tissue that usually surrounds the knee was completely peeled of the bone through the entirety of the gash. Just from the sight of the opening itself instilled doubt in my mind of the patient’s ability to walk normally again in the future. It was pretty disturbing for me to watch Dr. Billings wipe down the bone and then suction off blood in between the bone and the flesh, flapping the flesh around. I remember cringing my eyes from the sight and sounds created by the undertaking. To my surprise, Dr. Billings was complimenting on how clean the wound was, once he removed all the thick coagulated blood wedged between the tissue and bone. Once I got desensitized to the sounds and sights of the surgery, I began to really see the beauty of it all.

Just when I thought things were wrapping up, Dr. Billings took out an instrument that looked like what I can best associate as an ACME ray gun from the cartoons I watched growing up. It had a round funnel like opening at the tip that appeared soft and functioned by both sprayed and suctioned fluids. The instrument was turned on and Dr. Billings was quick at work irrigating the gash and then sucking fluids right back up. After twenty minutes of cleaning the opening, the wound was considered clean enough for the samples of tissue and blood to be taken. Swabs were used to accomplish this feat, swabbing to extract tissue in between the bone and the tissue of the knee. Once everything was done, Dr. Billings began to suture the tissue up a little bit. He did not suture the entire opening closed but more to hold the tissues of the knee against the bone. The opening was still very much open and exposed to the air. More of the black sponge was cut into strips to stuff the opening. Some light suturing was done to keep the tissue and the sponge flush together. A giant clear tape cover was used to saran wrap, if you will, the top of the entire opening. A small hole was cut into the tape, a tube was inserted, and a compressed bulb was placed at the other end. The bulb at the other end function to create negative pressure and suck out any pooled blood and acting as an indicator of how much internal bleeding was occurring. I was astonished at the bulb because I have never seen it used in this manner before. In the end, the leg was wrapped up tightly and the swabs were sent out to pathology. I am crossing my fingers that pathology comes back clean so the patient can keep is leg.

This observational day was the longest time I spent at the OR, cranking in at monstrous 16 hours. Good practice for residency I thought. I had a very rewarding experience in the OR today. In my wake, I had the pleasure of observing a radial bone repair of the hand, a sentinel lymph node biopsy, a laparoscopic colonoscopy, a part of a total thyroidectomy, an inguinal hernia repair, and an emergency throat tumor removal. A shout out to Dr. Billings, Dr. McDonald, Dr. Boudreault, Dr. Lim, and the podiatric and medical students that is extremely helpful and approachable. I meet a lot of new and familiar faces today. Just another reason to be excited to be a part of OREX. Until next time, Jimmy out.

On my observation day, I was in general surgery with Dr. Chong and it was something else. During the meeting, Dr. Harken talked about how oxygen delivery is caused by cardiac output, which is the length and intensity of exercise. This factor helps increase our quality and quantity of life.

After this wonderful lecture, I went into the OR with Charlie, a UCSF medical student and Dr. Chong, who surprisingly was my doctor in Kaiser Hayward. He was going to take out my appendix, but that was ruled out. The first surgery that we saw was an umbilical hernia, where Dr. Chong had his whole finger in his belly. After watching this short surgery, the next patient came in with a right Colectomy. That patient had pre-cancer and they wanted to remove the risk of it growing into a tumor by taking that part of the colon out. I saw as they prepped the patient and most importantly go over the comprehensive surgical checklist. There was the “sign in,” which had a list of checkpoints before the patient transferred to the OR bed. The “time out,” which was another checklist before the patient is cut. Finally, the “sign out,” which was a list of checkpoints before the patient leaves the OR. For this surgery, they used a camera and microscopic instruments to cut and shear the colon without actually cutting her open.

The doctor cut part of the colon out until they finally removed part of the colon with the appendix through her belly button. Honestly, it was worth the six hour observation because it was huge, I thought it was going to be a small portion but it was huge and I got to see the appendix! After they took out the colon with the appendix, Dr. Chong finally came in and performed a reanastomosis. Charlie explained that a reanastomosis is when they connect two tubes together to help heal the colon and resume with proper bowel movement. He also explained that if there is too little colon, then they cannot perform a reanastomosis and as a result, a permanent colostomy bag is required. We would have a non- reanastomosis if there were too much cancer on the colon and we would not be able to connect it to another tube. This was one of my best observation surgeries.

I was late to the morning teaching; arrived around 8A.M to Highland and went directly to the OR. I saw Dr. Harken talking to Dr. Lim second year general surgery resident; so I joined the team for the rest of the day.

First patient was in her sixties complaining of chest pain. The patient had a Pacemaker 10 years ago because of third degree heart block and was stable until lately where the battery of the machine is no longer working which needed to be changed soon as possible. Let’s talk a bit about what is heart block? As the name says “Block” it means that the electrical drive pathway of the heart from Atriums to Ventricles is blocked somewhere (see picture 1). Usually the cause of this block is a fibrotic tissue came from either aging, side effects of medications, or diseases. We classify the block on three degrees. First degree there is slow electric conduction from atriums to ventricles, in the second degree there is an asynchronous between the atriums and the ventricles sometimes ventricles contract after atriums sometimes not, and the third degree is when the ventricles contract independently from atriums. To regain the heart beat synchronization, we need to coordinate between atriums and ventricles by a Pace Maker (means it will speed the electric activity from atriums to ventricles). It has two wires one connected to the inside of ventricle and the second to the inside of atrium, from that the machine will know instantly when the heart is contracting and which cavity is delaying (see picture 2). The surgery was easy and fast, after injecting of anesthetic drugs Dr. Lim made an incision on the old surgical scare and took out the old pace maker after disconnecting it from the wires that had been introduced to the right heart cavities and fixed a new machine in the same place.

The second patient was 62-years-old, with a history of Coronary Artery Diseases -had three stents on 2010- complaining of chronic and intermittent chest pain. A second degree heart block was diagnosed with a severe bradycardia 35 beats/min (it was a second degree type 2 or Mobitz II block). I talked to the patient in pre-op for awhile with her niece, a bit stressed but she was smiling at the end when the circulator came. After skin sterilization of the chest and neck, Dr. Lim made a small incision below the left clavicle guided by Dr. Harken. She stuck the left axillary vein and introduced a wire toward the right ventricle. X-ray with scope was used to make sure that we are in the vein toward the right heart not in the artery toward the left heart. First, Dr. Lim pushed a ventricular pace maker lead guided by the wire and the X-ray toward the right ventricle. A very funny technique; first we need to push the lead -we saw in the screen that the lead was driven by the blood flow to the pulmonary artery- from that we need the retrain the lead few cm until it became straight (not curved) then push it again “but fast this time” in the way that it will be driven by the blood flow from the atrium to the bottom of the ventricle; the lead has a hook like shape which can stick easily into the trabiculated (not smooth) ventricle wall. Second, is the atrium lead guided by the atrium wire and the X-ray, this lead should be fixed perpendicular to the ventricle lead. Dr. Harken explained for as with looking to the scope screen how the two leads move with the heart beat, first the atrium lead then the ventricle lead, if one of them move abnormally or lately; a signal will be transmitted to the Pacemaker which can synchronize it. After making sure that all leads were placed and fixed in the correct place, Dr. Lim connected the leads to the Pacemaker and fixed it in subcutaneous bellow the left clavicle. A technician from the Pacemaker’s company was there with a special machine to program the Pacemaker in the safe way for the case (depending on the heart rate and the energy consumed by the heart in each beat).

Third patient was a 64-year-old diagnosed recently with Tonsillar cancer, in the need of chemotherapy. A port-vein catheter is necessary to deliver medicine safely. I also talked to him in the pre-op station. He was not stressed but he was a bit upset about the anesthesiologist who didn’t find a good vein for IV. The patient’s mother and sister were there, we laugh a lot when I asked the sister is the patient related to you? She said yes “I am his brother” and then the mother said so “I am the Daddy.” After skin sterilization of neck and chest, Dr. Lim put a central line from the right jugular vein guided by ultrasounds and introduced a catheter through toward the right atrium, ideally into the superior vena-cava. She made an incision 2cm below the right clavicle where she fixed the chemo-chamber reservoir beneath the skin. It has a silicon septum where the nurse can stick needles easily and inject the chemo-drugs. To connect this chamber to the jugular vein catheter, the resident made a subcutaneous way, then passed and connected the catheter into it.

Fourth patient was a 70-years-old with End Stage Kidneys Failure who is in dialysis almost a year. He is a Mexican man, moved seven months ago to the USA to live with his son. I talked to him, he doesn’t speak English but the patient’s neighbor was translating to me and to the staff. He likes the US and he wants to stay here to the end of his life. He receives dialysis three times a week through a central line in the right subclavicular vein, which is at high risk of infection and sepsis. The surgery today is the arterio-venous fistula, where Dr. Lim and Dr. Harken made a fistula (a communication) between the Ulnar artery and the Ulnar superficial vein using surgical magnifying glasses. The Principal of the technique is that arteries are small, strong vessels with high resistance, and thick walls (for that we feel the pulses) but veins are large, weak vessels with thin and muscle-less wall (low resistance no pulse, for that veins can dilate easily and widely without rupture). So because arteries are strong vessels, when we communicate an artery with a vein; the high artery pressure will be transferred to the vein, but because the vein is low resistant, the wall will dilate –after surgery it becomes bigger and easier to stick a needle in to- Try to palpate a vascular fistula when you have a chance (like in the ED, usually patient is in room 12) you will feel a thrill indicating a high blood flow transferring. After making an incision in the lateral 1/3 lower left forearm, a superficial vein was readily under the skin but the Ulnar artery took some time to find, guided by its pulsation. Because of the patient’s age, Dr. Harken had pointed out for us a fibrotic tissue surrounding the patient’s blood vessels; we need to make sure that when we suture these vessels to keep the fibrotic tissue outside the lumen of the fistula (otherwise it can be a risk of fistula thrombosis).

The last patient was a 54-year-old patient hospitalized in the ICU; she had a third degree heart block in need of a pacemaker. The ICU staff brought the patient to the OR. The surgery had been in quick and safe conditions. Here the end of the Full day iVascular Surgery.

Today I looked at the white board with great anticipation and excitement for seeing amazing surgeries. I scanned the surgeries for the day and the C4-C5 decompression soon caught my eye. I scrubbed in and prepared for the surgery. I wasn’t too certain exactly what C4-C5 decompression is or how the surgery will be performed but I was thrilled to learn. A cervical spine surgery seemed very risky. And cervical decompression sounded like they would be reducing the C4-C5 disc. I was immediately curious if they would be sawing the bone off to reduce some type of nerve pressure. I sat and watched the surgery team prepare the patient for surgery.

I was able to discuss the patient’s history with one of the nurses before the surgery began. I learned the patient had been having very devastating pain with the nerves in his hands and legs for several months now. The patient was in his middle 50’s and had numbness, tingling, and severe pain due to his C4-C5 disc degeneration. The nurse walked me to his X-ray to view the bone that had been putting pressure on the patient’s spine. Looking at the x-ray it became very noticeable how the bone was pushing against the spine. There was also another problem the patient’s C4-C5 disc had degenerated over some time, which was another cause of his pain. I could see the two bones almost sitting on top of each other with very little space in between, in comparison to the other bones which all had apparent space in between each one. The nurse informed me that aging caused this and there was no exact cause of the degeneration or the growth of the bone that had been pushing against the spine. She ensured that the surgeon would be able to cure both problems.

I learned the goal for the surgery was to first reduce the bone that had been putting pressure against the spine. This was done by a sort of sawing off of the bone back to a safe size relieving and reducing the pressure against the spine. It will no longer sit against the spine. Next the surgeon will insert a device to open the space between the bones that had degenerated and had fallen on top of each other. The device will be inserted and slowly opened to allow the necessary space between the bones. The surgery took about 4-5 hours and went smoothly. I was happy to know the patient would be relieved from the horrible pain he was receiving.

The next surgery I witnessed was a left breast tumor re-incision. It was a 37-year-old woman patient who had surgery several months prior to remove the cancerous cells. The doctors found suspicious cells and wanted to go back into the breast and remove more cells to ensure the cancer would not return. The patient was already prepped for surgery when I arrived into the Operation Room and the first incision into the breast was soon to happen. Two senior residents were performing the surgery under the direction of a surgeon. The residents seemed very skilled and it was clear they had performed this surgery before. This was interesting to view because the cells were removed via laser and suspicious lymph nodes were cut out. The surgery went smoothly and hopefully the cancer will not return.